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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FAC' SITE NAME FACILITY CONTACT NAME <br /> F Bablca <br /> A Distributing Co. Uavu Chavier <br /> C <br /> I FACILITY ADDRESS SITE PHONE N with AREA CODE <br /> L 1245 W. Weber Ave. None <br /> I <br /> T CITY STATEZIP CODE N of TANKS <br /> Y Stockton Ca I <br /> at SITE 2 <br /> A AffLICANT/PILLING NAME APPLICANT CONTACT NAME <br /> P Hank of Stockton <br /> P Dave Clavier <br /> L <br /> I HAILING ADDRESSISO. Bx. �� APPLICANT PHONE N WITH AREA CODE <br /> A } q4i_11112)0 <br /> N CITYJSTATE ZIP CODE TYPE of APPLICATION <br /> I ;�I•s,c.lCl,c,rl {;<1 9,)c, 11 I Ci.OSURE, INSTALLATION, etc. I�lln )yJa l <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January I, 1991) R $100.00 <br /> I f <br /> V <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) 1170/TANK (after January 1, 1991) <br /> F # Tanks 1986 1 1987 1 1988 1989 1 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply N by fee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE - $56.00,each TANK (Due every 5 years) See California H R S Code, Section 25287 <br /> I <br /> T N Tanks x (56.00 1986 through 1990 1991 through 1996 <br /> Y (enter smou7t and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> C <br /> L CLOSURE FEE ■ $53.00 per hour (3 hours minimum per TANK) N TANK(s)—L'— X $159.00 ■ $.31 3 }�� <br /> 0 <br /> S . <br /> U TEMPORARY CLOSURE (A one-time permit, for review/Inspections) TANK I.D. N(s) <br /> R <br /> E TEMPORARY CLOSURE FEE - $150.00 each TANK N TANK(s) X $150.00 ■ f <br /> P PLAN CHECK (Install. Plan Review b Construction Inspections) TANK I.D. N(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) _ $424.00 minimum f <br /> R REPAIR FEE (workp(an review 6 construction Inspections) TANK I.D. N(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) N TANK(s) X $159.00 S <br /> A <br /> R PIPING REPAIR FEE _ $53.00 per hour (3 hour minimum per facility = $159.00) f <br /> H CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> 5 <br /> C FEE = $53.00/hr FEE = S53.00/hr FEE = f 53.00/hr <br /> TOTAL DUE [ $318.0o <br /> OFFICE USE ONLY <br /> ..................................w........................................ .................. <br /> ................,.....................................................,.........................................................,.............,........ <br /> w» ■..»,.+. ,.�::::..:�.«�..�..»...■.««»»,......+.�..w.».■n■....r..n....w..■..r,.n.�..�»..■..■...�.. ..■««»»,»».�.■....■..r«..M..r..u...a..rr. <br /> so wws" MAww �' °°" `L'�"E�""' 't `�' P'1�'d ll°"�` r�wwwww �f�`" <br /> w wwwww <br /> S A <br /> InA <br /> ■.......................... .......... _ ?,:..................... .....�... ........ ......... ......... ........................ .... a....:E.�.....................� <br /> .................... ...................... <br /> ,...> ,...■w..Mww.w.�..r»».w.■»iw.»M»,..»w..,....w..>r..w.�.W <br /> ».wr■..a ww,ewwwwwwwwwww #N"www,w,rwwwwwwwwwwwwwwaxwwMMwwwwwwwwwwwwwwwawuwww�wrwwarwwwwwwwwwwwwawwwwwwwwwwwwwwwwwwrwwwrAwnwwwwAWAW <br /> EH 23 032 (REV 1/10/911 ft Paoe I <br />